Comp, call, location. That’s what most physicians compare. Alex Fernandez says the thing that actually decides whether you thrive or burn out is how well the business runs, and almost nobody checks it.
Alex started at the front desk of a doctor’s office in the early 1990s. Thirty years later he’s CEO of Synergy Orthopedic Specialists in San Diego, and he’s been on both sides of the hiring table.
In this episode:
– The financial KPIs to ask about before you sign: overhead ratios, days to collect, collections against charges, payer rates versus the community
– Why large groups buy you leverage and cost you autonomy, and when independent is the smarter move
– How to evaluate a hospital-employed offer, from referral structure to whether anyone’s actually marketing you
– What a CEO is quietly assessing about your spouse, your family, and why you picked the market
Explore physician jobs → pacificcompanies.com
Subscribe wherever you listen.
#DocLoungePodcast #PacificCompanies #PhysicianPodcast #PhysicianJobs #PrivatePractice #PhysicianContract #DoctorCareers #OrthopedicSurgery
Full transcript:
Stacey Doyle (00:01.86)
Welcome back to the Doc Lounge Podcast. I’m your host, Stacey Doyle, Senior Director of Marketing at Pacific Companies. And today I’m joined by Alejandro Fernandez, CEO of Synergy Orthopedic Specialist and a healthcare executive with more than 30 years of experience building and leading multi-site physician practices. Alex brings a unique perspective to healthcare leadership because he truly worked his way through every level of practice operations. He began his career at the front desk in the early 1990s and went on to spend
Three decades helping physician groups improve their operations, scale effectively, and better support their providers. In 2024, Alejandro was named Practice Executive of the Year by the American Alliance of Orthopedic Executives. He also served as president of the South Florida MGMA chapter. Today we’re discussing what physicians should really look for when considering a new group and what a CEO is evaluating when a physician wants to join.
We’ll explore why the business operations behind a practice can directly affect physician compensation, admin burn burden, burnout, and long-term success. We’ll also discuss how physicians can recognize a well-run organization before they sign an agreement and why the right fit may sometimes be smaller or independent practice. So, Alex, welcome to the Doc Lounge Podcast. We’re excited to have you.
Alex Fernandez (01:21.198)
Thank you, Stacy. It’s been a pleasure. Thank you for for having me. I d you know, I I know that particularly physicians starting out or physicians that are looking to change their careers reach out to you guys all the time and and are looking to try to figure out what their next step is, whether, you know, as locums or or they’re looking to hire, you know, to to find their next opportunity. So thank you for having me here. Really, really appreciate it.
Stacey Doyle (01:46.331)
Well, we’re excited to have you and I wanna give you some, you know, an opportunity to tell us a little bit about your background and really what, you know, that experience has helped you now as you’re leading physician groups today.
Alex Fernandez (01:59.788)
Yeah, I mean I’m I’m glad you brought up the the part about the front desk. You I I people ask me all the time how did I get into this? And in truth, I was studying advertising and business administration and you know, for my undergraduate. But my parents are immigrants from Cuba. They didn’t really have, you know, I didn’t have like I did for my kids, the fund set up to to go away to college, et cetera. And so I had to pay my way through through school. So I needed a job, I needed it. So I went to school and at the same time I
I I had a part time job and at the time I needed a job and I got front of staff at a doctor’s office. I mean, like that’s how I got into healthcare. My parents are not physicians, they’re in the retail industry and my family a lot a lot of my family’s in the retail industry, my brother’s also in healthcare. And that’s how I started. So from there just over the last thirty years, helping physicians. I mean, I do have an MBA from healthcare in healthcare administration from University of Miami and I’m very proud to be you know.
graduate and but in reality just started from from the beginning from the ground up and over the years I’ve been involved in private equity deals in gastroenterology, cardiovascular dermatology, currently now running an orthopedic medical group that’s independent. and I think there’s different flavors for different folks. I’ve been involved in small practices. The first practice that I ran was a three doctors office, which currently those guys are still around in the same way they were before and they’re close to 10, 12 doctors.
So the the practice is mature. Physicians have to figure out I would th say that they have to just kinda like date, you know, they have to kind of first figure out the people. Do they blend in? Is it their personalities? It’s not just about the specialty and branding, but I is is it where you wanna be? Do you feel like this would be somewhere you would want to spend a significant amount of time? And and more than ever, physicians stay well, before they would stay forever. Now I tend to think that
they at least make one or two moves in their careers, maybe more, depending on the on the type of business that they’re in, if they’re working for hospital systems or healthcare organizations, P back, not P back, et cetera, small groups, large groups. For sure there’s a lot of flavors. So I I’ve been involved with many and look forward to providing feedback on around that to your listeners.
Stacey Doyle (04:17.018)
Well, I love that. And I think that’s a big piece here because I know we obviously speak with physicians all the time and they’re focused on compensation, they’re focused on call, you know, location, what those clinical responsibilities may be. But it sounds like you’re you’re telling us there should they should also be examining the business itself. So tell us a little bit more about that.
Alex Fernandez (04:39.201)
Yeah, I mean particularly I I well I always start with the fact I I tend to be biased around this, but I think bigger is better. the larger the organization is, whether independent or not, the more capabilities they have, the more financial strength they have, because at the end of the day, we negotiate rates based on strength. The payers will come in and say, Hey, I want to pay you, you know, on Medicare, you know, one one to one term Medicare or
If you’re part of a health system, maybe they pay you on a percent of charges. So the the larger the organization, the larger the infrastructure, the larger the opportunity. But I think as it gets larger, it also loses a little bit of that. I think physicians go into medicine not just because they want to be physicians and they want to help people, but they also there’s an entrepreneurial part of their their in their in their choosing and and you know this. I mean they’re they’re they they go through, you know, it is eighteen, twenty, in some cases twenty years of learning.
And the whole idea is that at the end they want to be able to have their name on the door. They want to be able to have this opportunity where they control their destiny, they control clinical care, they manage the the business in one way or another. so I think the larger the organizations are, the harder it is to do that. smaller organizations, you have a lot more autonomy around your you what you say, c not just clinically, but just your staffing, how many employees, you know, you might be a dermatologist and you want
several PAs that work with you. You have you want several medical assistants to ass assess and and help you take care of patients. And in large organizations they’re gonna say, well, that’s an extra cost. maybe, yeah, the one PA is great, but not two. And then one medical assistant, not three. So I think the large organizations, there’s they they do bring in a significant amount of of opportunity for revenue and resources, but at the same time you lose a little bit of governance and control over your your business and what you want to do.
Stacey Doyle (06:33.498)
Great insight there. Tell us about, you know, obviously you’ve have evaluated a lot of practices. So if you are a physician that’s thinking about, you know, making a move, what are signs that you can tell that it a practice is well run?
Alex Fernandez (06:51.601)
it starts, I would say, from from the physicians themselves, physician leadership. are are they happy? Do they feel that this is a great place to work? is there an opportunity where the the the leaders or the physicians that you’re talking of feel that there that there’s financial strength be behind the organization, particularly around independent practices? you could go into a a practice of 10 or 12 and you think, well, that that’s a large significant large group, but it’s not.
professionally managed, that there’s some issues around revenue cycle management. Maybe the contracts haven’t been touched in years. And so I think that I go back to the idea of dating. I think it’s great that you, you know, particularly if you’re doing locums, it is what it is. You’re going in, doing your job, and then you get out. But if you’re going to be looking for a long-term opportunity, long-term relationship, it’s almost like dating. You have to talk to people several times. I think that physicians don’t spend enough time in saying, okay,
I’ll come in and I’ll spend a couple of days, not just the day that they invite me and go out to dinner, but you know, spend a couple of days with the practice. F shadow the doctors, talk to them. Because I think as time goes by goes by, the physicians will be more open to sharing, particularly the good, but they’ll start sharing also the weaknesses or the the issues that they personally perceive that the organization has. they might tell you, you know, whether it’s, you know, we they feel like they need more staff or
they they’re not allowed to do a certain thing because the organization doesn’t want you know, there’s capital it’s capital intensive and the organization doesn’t want to pay for it. And you’re like, Well that’s very c clear, that’s that’s actually something that might be very important to you. let’s say a physician that that needs access to a C T scanner and ever if you have to the organization has an MRI and X ray and then and that’s something that’s critical to your expertise, you might be all you know
somebody that does ultrasound guided endoscopy and that’s not in their ASC. So all those cases you have to do them in the hospital. So I mean I think that it the key is spending some time and finding out clinically and business wise what are the things that are going well. But if I look for specifics around key performance indicators, for me, for example, if I went to look for a job with a with a medical group, I’d be asking around overhead ratios, I’d be asking around key performance indicators, the days to collect
Alex Fernandez (09:17.897)
revenue, percentage of revenue collected against charges, rates compared to other rates in the community and so on. Some things they could tell you, some things you have to sign NDAs for. But I think that again, if if the physician spends the time, and particularly if they’re courting a couple different groups, I think it makes it behooves them to make sure that they don’t get aligned with another group by chance. Because typically if it’s good then it will be good forever. But if it’s bad, y I mean you might have to have relocated
maybe you have to move your family. There’s a a big opportunity and I think that there’s a a a percentage there’s this thought around that investment that you already made. And if the investment’s going down, call it a in in a negative way, it’s it becomes starts becoming a loser. It’s hard to cut that loss because you’ve made such an invest big investment by going in and bringing your family and changing your name and putting your name and credibility behind this particular brand or particular location.
and if things are not going well, i i it’s just harder to get out. So I think that it it’s very important that the physicians do as much diligence on the business as the business is doing on them.
Stacey Doyle (10:30.936)
that’s great practical advice that I think physicians, you know, can obviously use and and I really appreciate that dating analogy because it sounds like they need to also be listening for some of these negative things that could, you know, that you can uncover. And it sounds like having those list of questions handy is something that could really kind of help aid in that discovery. Are there any other
Other questions that you want to recommend to physicians so that they kind of go in most prepared?
Alex Fernandez (11:05.185)
Yeah, I I think lifestyle is very important nowadays. we we all wanna work very hard, but it’s not like how it was before where you would say, Okay, I’m gonna go be on call literally two hundred days a year and and I’m gonna work seven days a week and and so on. And again, to a degree if you’re starting your own practice from scratch or taking over somebody’s practice, you might be doing that anyways. But if if you’re looking for a lifestyle, understand the community you’re gonna go into. Understand the what the partners are like.
Do they like each other? Do they go out to dinner? Do the do the wives know each other? I think that that’s also kind of like a second layer outside of just the business, but the culture and the environment and the organization wherever you’re gonna be, or are you gonna just go in there and just kind of be like on your own? who’s gonna mentor you? There may be you’re you’re a new cardiovascular surgeon and you’re going into a particular market. Are they gonna feel like you they hire you, but your competition?
Or they hired you and then there’s all this excess business that they’re gonna feed you or and and particularly what are the dynamics, the financial dynamics for the partners to be able to if they bring you on board. So I think there’s for sure a lot of other layers on a lot of the questions. I mean, we literally could spend hours on this. I would have to I always have to think about it. I would I might have to like come up with like, you know, the top, you know, hundred questions to ask. It’d probably be a neat thing to to do, hundred questions to ask when you’re thinking of joining a medical group and and and can you
get all those answers. I mean, some of them might n they might not be able to give you answers to. So but I think you’re making a big move just as they are.
Stacey Doyle (12:39.362)
And thinking about, you know, obviously we work with some, you know, of the very large hospitals and healthcare systems across the US. Give us a few questions that they can ask you know, physicians could ask if they’re going if they’re looking at one of those type of settings as well. So they can compare.
Alex Fernandez (12:56.001)
Yeah, I think I think it funny enough, I think when you ha you’re in an employment model and that you are not you don’t have to worry about certain things. I mean, there’s always that that, you know, work RBU component. Hey, you have to work X. But when you’re working for a health system, typically they’re set up in a way that the structure, particularly around referrals from primary care doctors or from other specialists, is kind of built in. They already develop a significant amount of performa and and and
There’s some financial analysis that was done prior to making an investment on the physician. So I think again, clearly the there the relationships are a little bit different. You know, your head of your department, maybe the CEO EO or CO of the hospital, trying to understand where do you fit into this whole realm? Are they building a new division? Are they building a new department? Are they growing the department? Is it because some physicians are retiring and you’re coming in to replace them? And some of those things are pretty clear. But I think.
The the intangibles are always the most important things that we we don’t really talk about and we we don’t worry enough about, which is, you know, the culture of the org of the c organization, you know, the financial structure of the hospital. I mean, we know their hospital systems are closing down. Well, not hospital systems, but the hospitals themselves are closing down. In some cases, smaller hospital systems are being bought out by by the health systems. so it what’s gonna happen if you’re working in in a particular
deal and then all of a sudden they bring they merge this two hospitals, are you gonna be out of a job? I mean for sure that non competes nowadays are are pretty much gone throughout in most states of the United States. They’re not really enforceable, but are you are you gonna move? Are you gonna leave? So I think doing similarly, it’s a little bit different legwork, but doing some legwork around the intangibles, the the culture, what’s going on with the the overall health system’s financial being, board directives,
You know, the where where’s the organization going? Are they stagnant or are they just trying to feed the the a particular community? Maybe if they’re role, they just need this job because again, the the the need is there and they haven’t had success in bringing doctors from the community to to fill those roles. So the last thing also you want to do is just show up to a job and find out that there’s no real marketing plan for you and you’re just gonna sit around and and wait for people to show up. And it’s like I get.
Alex Fernandez (15:19.189)
If you’re getting a salary, that’s not bad, but that’s not gonna be a long term solution. At some point in time, whether you’re going into private practice or into a hospital system, you wanna be the shining star. You wanna be the person that’s going out there, that’s recruiting, that’s talking, that’s you know, doing the grand rounds, that’s speaking to people. I think dealing with hospital I would say politics is important.
And understanding, you know, kinda like where you fit into the whole model. But that’s not any different than when you’re trying to join a big group. You have to also fit where do you fit in the big group in regards to the the the politics of the the overall group. So
Stacey Doyle (15:57.339)
Very insightful. Now tell us, obviously, you just you mentioned some of the benefits of large groups. It’s the resource, the infrastructure, that stability, but that isn’t always the right environment for for every physician. So when might a smaller or independent practice be a better choice in your experience?
Alex Fernandez (16:15.607)
Yeah, I think it goes back to your personal preference, the physician’s preference. do they, you know, the again the community. Are they going to a rural community? Are they going to urban community? Are they going to they want to live, you know, in Texas versus living in California where you know, I mean, for me I I worked in New York City, Miami, Florida, and now in San Diego, California. I mean it’s like three completely very different markets, but I I, you know
I love all of them. I mean it just you know, so you have to kind of figure out where where you wanna be and w so I think location and you mentioned that early on, people worry about where am I gonna go and how much money am I gonna make. But once you where you wanna go, the question is are you gonna be in, you know, 30 minutes or an hour away from the metropolitan area and that’s where your clinic at, even though it’s in the in the market area or the DMA because that’s where the need was. or are you gonna be
like in the middle of the city and that might not be something that that that you would like. Then now talking about smaller or larger, you might go to a larger practice that puts you where they need you, or you might go to a small practice, i.e. small as let’s say if a solo doctor that’s just hey I started my practice and I want a part I want a second partner. I want somebody to kind of come come in and share a call with me, somebody that’s gonna share my expenses and resources with me. do you fit into that? So I think it’s a lot of it is around
personal preference and kind of fitting. I tend to feel that the smaller practices have a much harder time in trying to grow or develop financial metrics that make sense for them. again, if you’re one solo doctor and you bring a second one, you’re sharing resources. So that’s going to be better for the first person. But if you compare that to joining maybe a seven doctor group, then there might be better metrics than a seven doctor group. And if that seven doctor group is part of a
call it a thirty-five doctor group that with you know that basically a smaller group within a bar a bigger MSO, then that might be even better at metrics because you’re getting this call it a small group feel, five, seven doctors, and then you’re part of a much larger organization that’s negotiating rates, being in professional management. So I mean I can again I’m tend to be biased. That’s kind of the where I live. I live in that, you know, thirty five to a hundred doctor range. you’re able to
Alex Fernandez (18:39.167)
nowadays having ants access to ancillary services is extremely important. One for patient care and continuity care and ease of referrals, et cetera. But also at some point in time you’re gonna become a partner. And if you are a gastroentrologist, you wanna be part of the ASE. And if you are as a gastroentrologist, maybe you do a lot of IPD. So you want to be able to have access to an infusion center. You wanna be able to have maybe access to a pharmacy. You wanna be able to have
access to or you want your your group to maybe own anesthesia because anesthesia might be a re a revenue generation. it might be they they have a CT scanner and therefore you make some money around advanced imaging. Maybe they do research and you’re interested in doing research. Maybe they are maybe they have a fellowship program and you’re able so e even independent practices, our group in particular has all the things that I just mentioned. You know, we have the ASE, we have physical therapy, we have DME.
we are an as CCologist are are employed by the group. So they feed the the ASC that the practice owns. So understanding also the dynamics around not just employment, but the track to partnership, two, three years, how much could it be? How much is it going to cost? Maybe you don’t know 100%, but what is it costing right now versus what it’s going to cost in three, four years when you do become a partner? What are the financial metrics to get there? So again, it might be it might make sense. I don’t want to deal with any of this. I want to be, I want to go into a small group.
With three docs, I’ll be the fourth, and I understand how the everything’s gonna work and I understand the the metrics to being a partner and that’s where I wanna live. And particularly it might be in Austin, Texas, where my wife is from, and that’s where our our in laws are at, and we’re gonna have kids and we wanna be in this great community that’s that’s growing. I mean, you you tend to follow your particularly the physicians I always when we’re negotiating it’s like, where’s your wife from? Are they are they in do they live in San Diego? Are they where are your in laws?
They’re like if the answer’s no, I know that I’m competing with somebody else. I’m competing with with another health system or group or something because that’s really where the family particularly if they get along with their loss. That’s where they wanna be. You wanna be with family if you can.
Stacey Doyle (20:47.49)
And I know we we talk a lot about, you know, really fit runs both ways. So when when you’re evaluating a physician who wants to join your organization, what qualities tell you that person might thrive within the way that your group is operating?
Alex Fernandez (21:04.139)
Yeah, I tend to think nowadays we always we we look for like if talent comes to us, we might not be looking for somebody in particular. But let’s say I might not be looking for another sports doctor. But if a sports doctor comes to our, you know, wants to be in our market and maybe they’ve been in practice for a while and I just did this with pain management. They were in New York, they’re originally from from San Diego, trained down here, family’s here.
I think the dynamics are like for me is like there has to be, particularly in certain markets, the connection. New York City was super easy to hire. Everybody’s young. They just finished their their programs, their residency programs, and they’re like, I want to stay in New York. And it’s like for me, it was like which which practice can I put you in? I have one that’s more clinical dermatology, one more cosmetic dermatology. If you have most training, I want to put you in this location because they have all the setup for Mo’s and then we have the pathology lab. Where in Jersey
Literally a cr it was so much different trying to recruit. It was like, no, I don’t want to live in New Jersey. I want to live in New York City. I’m like, well, live in New York City, come and work. Like, no, I don’t want that. So it’s like it the in some places it’s really hard to recruit. we have practices in in Orlando. Well, you know, Orlando is really cool to recruit, but some people don’t want to live in Orlando. in and so on. In San Diego, I always feel that it the the dynamics around compensation, San Diego is a very expensive.
city to live with, but the compensation overall tends to be lower than most markets. Other particularly other other markets can pay an orthopedic surgeon or can make so I always look at it’s like, are you coming here because there’s family? Are you coming here because you’re looking for a lifestyle? You like surfing? You want to be able to finish your practice at four o’clock or start at nine and go do this or do that, or you’re active, you’re a runner, you’re a hiker. What what is it that’s attracting you to our practice? And I usually do it that way.
I wanna make sure there’s a fit from them that more than that is a fit from us, because if we feel it’s a there’s a fit, usually there’s gonna be a fit the other way as well. spouses for sure or partners, they have a big key say in what how decisions are made. I know that I do that for me, for with my wife, that somebody called me up when when I got this job and they said, you know, the opportunity is in San Diego. And immediately after I finished, I called my wife and said, Hey, what do you think about San Diego? And she’s like, When are we moving?
Alex Fernandez (23:27.543)
Versus if I would have said probably anywhere else, I don’t know, not n I don’t want to put negative around any particular market, but in other markets it yeah, she likes water, she likes coastal, and she likes warm weather. So if I told her out New York was hard, believe it or not. It just going to New York, it was a great opportunity and and exciting for us, but at the end the spouse has a lot to do it. So I’m always looking to see where’s that connection, is it family sort of the money and everything else just will land.
If it wor if it works, if we have a budget, they have a budget. And if it we can meet, you know, if everybody can be unhappy, I think we’re happy. that works well. So I think the key there is is finding the right people. And then personality as well. I think that I like to have several interviews. I like to have, you know, the t the telephone interview, I like to have a personal day meeting, probably a full day meeting with multiple people, show them around different offices, have a meet and sit down with different doctors.
Preferably another day if it’s possible so that they follow with one or two doctors so we get to see and talk to them personally. Maybe if the if it’s a surgical procedure, make sure that they go into the ASC the hospital and do rounds, et cetera. Just kinda get feeling it. Preferably just with one doctor, I prefer that they do it two or three. So we have a consensus as a group. Yes, this is somebody we wanna not necessarily just hire. It’s somebody we want to invest in because it takes a lot from
credentialing, billing, training, staffing. We have to build a whole biosystem around them, staffing, et cetera, just making sure everything gels, everything makes sense. So if we’re gonna bring somebody on board, it has to really make sense for for them as much as it has to make sense for us.
Stacey Doyle (25:07.728)
Great insights there. So thank you for sharing kind of what you’re looking for and how how that works the other way around. So to wrap this up, I wanna just let you what is the single most important question you think a physician should ask if they’re gonna be joining a group? What what was that biggest question that you would recommend?
Alex Fernandez (25:28.357)
I think for every person it’s gonna be different. but I think that you have to look retrospectively at yourself and what’s really important for you and and your and the likelihood and try to find out why should they join this organization for the rest of their life? I know that that sounds really corny, that I’m gonna be here for the rest of my life, but as a physician, you almost have to think that way.
It what what is it that why should I come here and invest and be part of this for the rest of my life? Like start now and I want to be here to the day I retire. And I think if an organization can’t really answer that concisely, or has not taken the time to learn about you and your persona and your wants and needs, not just professional but personal, your career goals, your personal goals. And if those things don’t match up,
It’s probably not a good match. You should probably run away. because again, we typically do we we go into opportunities thinking they’re gonna be positive, and then we find out all the negatives, and then we feel like it’s so taxing to try to get out of it, to try to like you, you you you just continue trying to invest. I always compare it kind of like the stock. You buy a bad stock and it goes down in price, and you’re like, I hope it goes up, I hope it goes up, and you’re waiting for it to go up. And then instead of just cutting your losses early on and just moving on.
you kind of stick with it and then you you become this misery of a person that the and I and I feel like when I first came to this group there’s a couple of people that just didn’t live in they they didn’t like the overall idea that the group had. They wanted this very loosey goosey type organization instead of a very strong clinical operation and very strong leader lead physician led organization. And they left. And I think that’s actually the best thing. So if you’re gonna look for a job, make sure you it’s gonna be the job that you’re gonna have for the rest of your life.
Stacey Doyle (27:28.288)
Great advice, great wisdom and I really appreciate you sharing all of everything that you’ve learned to build s so many successful practices with our physician audience that’s listening and and trying to figure out, you know, how to determine where to go and and what moves to make. Alex, please share how anyone can get at touch with you and and and learn connect more.
Alex Fernandez (27:48.907)
Okay. Yeah. Yeah, for sure. on LinkedIn, Instagram, social media, YouTube, all of them, it’s Alex Fernandez MBA. So it’s easy. Just any any social media channel, Alex Fernandez MBA, and you’ll be able to reach out to me. And again, I’m I’m here to help out whichever way I can.
Stacey Doyle (28:08.005)
Fantastic. Well, thanks so much for your time. We really appreciate it. Just hold on one sec.
Alex Fernandez (28:12.94)
Likewise.
